Patient safety

Manchester trust slammed for its ‘deadly’ maternity care

Two hospitals run by Pennine Acute Hospitals NHS Trust have been making severe failings in their maternity care for years, leading to a string of entirely avoidable deaths and long-term injuries.

An internal review carried out by Pennine Acute’s new maternity director Deborah Carter into maternity care at the trust’s Royal Oldham and North Manchester General hospitals identified several “unacceptable situations” taking place at the hospitals such as the death of a premature baby in a sluice room and a mother dying from a “catastrophic haemorrhage” due to misdiagnosis.

The review, which was obtained through Freedom of Information requests by the Manchester Evening News (MEN), was carried out in June by new management from Salford Royal NHS FT, following damning reports by the CQC which led to both hospitals being rated as inadequate in February.  Professor Matthew Makin, medical director at Pennine, said that it had apologised to all patients involved for “any failings”.

He said: “Our new trust chief executive and the senior team wanted to understand fully the issues and problems affecting services, and what urgent action needed to be taken to improve patient care and to make our more pressured services safer and more reliable.

“These cases were, like all reported incidents, investigated thoroughly at the time and the families have been contacted and met by the trust’s head of midwifery to apologise for any failings in care and to discuss the changes that have been made. The priority is for all of the trust’s services to meet the high standards that patients expect and deserve.”

Carter’s report outlined several incidences of poor decision-making which has resulted in “significant harm to women”, along with “real issues relating to the management of women in labour” that have “resulted in high levels of harm for babies in particular, which has significant life-long impact”.

It also condemned chronically short staffing levels – with locums making up over a third of maternity ward staff –  and an “embedded” lack of compassion in the trust’s culture, highlighting a mother's “increasing deterioration” being wrongly attributed to mental health issues.

“The effect of poor staffing numbers in clinics has meant women have fragmented care, suffered long waits and not had appropriate management,” the report said.

“Staff attitude has been a feature of a significant number of incidents, from the most basic reports of staff relationship breakdowns, resulting in women and their families exposed to unacceptable situations.”

Pennine Acute claims its failure to release the report, which was heard in private in June as part of its new executive team’s wider review, was due to a “misunderstanding”.

Prof Makin offered assurances that the trust has used the incidents involved as part of its improvement plan for staff training and is now looking to address its failings via the recruitment of additional midwives and on-going clinical leadership support from Central Manchester NHS FT.

“We are steadily making the necessary improvements so that patients can receive reliable, high quality care across all of our services,” he concluded.

“We have fully reviewed our risk and governance arrangements including learning from incidents and complaints, and are making progress in improving the way we listen and involve our staff to address the long standing problems and challenges facing our teams.”

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